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ONSITE WASTEWATER TREATMENT SYSI EM PERMI I <br /> SAN JoAOUIN COUNTY ENvutoNmENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NONREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS t Z(Dot W. P L h-eT i 14Z-t> . CrtY/ZIP -M#N e4 <br /> H <br /> CROSS STREET L PrV"W"//E��R APN Z I Z—1 03 PARCEL SzE S- Ac. b <br /> OWNER NAME._ �� V-�5 LLt PHONE <br /> (- 3(o �p�T71V <br /> OWNER ADDRESS I Z�0.S-0 c O• HT1,L A-T -i 1 W CnY/STATE21P p� r`' •—� C A <br /> CONTRACTOR Ll�C o''''^� G�i JT.�`+J u`�-t— Nit' F�L_ PHONE 3&-/`.(A�3-IS' 1� <br /> CONTRACTOR ADDRESS 401 Kj- 0AIC-:.- '1 Cm/STATEJZP LVy l vt T �TZ�O <br /> LICENSE QC-42 QG-36 OTHER NUMBER EIIPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 1 BUILDING PERMIT* LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION ❑ REPAut/ADDmoN ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY 0 ¢OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal 8 OF COMPARTMENTS <br /> DISTANCE TO NEAREST: VVELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES C LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION R PROPERTY UNE ft <br /> ❑ FILTER BED WIDTH ft <br /> DISTANCE To NEARESTR PROPERTY LINE ft <br /> 13 MOUNDED WIDTH ft <br /> ft H <br /> DISTANCE To NEAREST ft A PROPERTY UNE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE To NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M RR'FjUTI/`�)U R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)951-7697 <br /> SIGNED TITLE C0^15 1VL7-r41A/f DATE 3`( &9�ZO <br /> 1- � - --�------ MFNT <br /> E�Vi�p <br /> 16 <br /> EPgRtMeNT <br /> DEPARTMENT usllirowy r <br /> Application Acceptetl ey Date Area Employee ID* <br /> Final Inspection By Date O SPECIAL PERMIT-Approved by <br /> Character of Soil to lhpth of 3,F Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Code INFO Cash Remitted DateServiceR uest# Invoice# Per <br /> Permit/ <br /> 71 Ajim 7)Poo III I <br /> -0r- ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />